03110007CITY OE CUI'ER'fINO
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BUILDING DIVISION PERMITCONTRACTnR`INFORMATIONu�_
Is
BUILDING ADDRESS: .
I VTMrqnT�RY PT
MORTON FINHILL
PERMIT NO. 03110007
-2—r44
" ER'S NAME:
MORTON PTN14TT.T.
PERMITMUEDATE
2
ONE:
SANITARY NO. CONTROL N0.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hcmby affirm that 1 am licensed under provisions of Chapter 9 (commencing
P
with Section ]") of Division 3 of dm Business and Profession Code, and my license, is
Lorane Class ermrf
License f Class Lk. N
REVISION --IN HOUSE USE ONLY
Dam Centimeter
NO NEW PERMIT ISSUED ORIG. 403010060
ARCHITECTS DECLARATION
1 understand my plans shall be used as public meet&
Licensed Professional
j OWNER -BUILDER DECLARATION
1 hereby from ohm I oro exempt room the Comranora License Law (.,,he
i following reason. (Section IIA L5, Busincss and Professions Code: Any city or county
which requires a permit to construct. alcor, improve. dcm ltvdi. of repair any structure
! priori its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant n the pmvisien of the Contmcturs Liwnse Law (Chapter 9
Sq. Ft. Floor Area
Valuatio$1O7
(commencing with Section 7") of Division 3 of the Business and Professions Code) or
. that he is eaempp therefrom and the basic for the alleged exemption. Any violation of
3 �,�A@19eI p p
Occupancy
P Y Type
Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty Of
not mom than five hundred d.11... (SK(B.
0 1, as owner of the property, or my employ. with wages as mei, to compensation,
will dome work. and me structure is not intended or offcmd forsale (Sec. 7044, Business
Required Inspections
and Prefrssions Codc: The Contractor's License Law don not apply to an owner of
property who builds or burrows thereon, and who docs such work himself or through his
own employees, provided thauuch improvements are not intended or offered forsale. If.
howcwt, the building or improvement is sold within one year of completion. the Owner -
builder will have the burden of proving that he did not Wild or improve for purpose of
sok.).
co 1, t owner of the property, . B exclusively contracting with:)cursed cnnuanars t.
comma the Business and Professions Code,:) The Conmrecor. Li.
not (Sec.
I \
come es
does not apply m an owner of property who Wildspor improves thcmon. and
o an
Q
who claw
who contacts for such projects with a eonoaaor(s) licensed pursuant to me Contractor's
Liamm Lbw.
/
Q 1 extrafitu�nsder Scc. B & P C for this reason
�ND
Date
P W 5 COMP N A DECfA
S
I hereby affirm under Penalty of perjury one of the wing declaration:
I haw and will maintain a Certlficam' of Consent to self -insure for Worker's Compen-
troom, Us provided for by Section 3]00 of the Labor Code . for the Performance of the
work for which this Permit is issued.
0 1 have and will maintain Wearkcr's Compensation In,..... as required by Section
3900 of me Labor Code,, for the performance of the work for which this Kim it is issued.
My Workers Compensation Insurance artier and Polity number are: ,
Cartier. Policy No.:
'
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Tbis.ection need not W comPlcmd if the permit is for one hundred dollars (g IOIB
or less)
1 certify mat in the perfnm.m. of the work for which this permit 0 issued. 1 shall not
employ any person in any manner u as tir Wemoc subject to the Workers Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this C(ertircam of Eaompion, you shouW
become subject to the Worker'a Compensation provisions or the labor Code, you must
' forthwith comply with such Provisions or this Permit shall be deemed revoked.
j CONSTRUCTION LENDINGAGENCY
lending agcnry for Ne, perfurmance of
1 hereby.'whi thi mat mem is
h s ed (Sect3
' the work fur which this permit is issued (Sec. l09], Civ. C.)
Lender) Name
Lcndcri Address
1 coniry that I have read this application and suite that the above orom atiun is
\
correct. 1 agree pc comply With city and county and ser laws relating
and hereby amhorim maLlwSeca
ematisxs of this city to enter upon the
y t a
�-
11wwngeontinsd ue
) alwve-memioned properly, forimpection purposes
trabsk
(We,) agree I. ssrc, indemnify and keep haomleas the City or Cupertino against
-
j
in re coauand expenses which may in any way accrue against said City
m eonsequcnce o )the granting of exphis permit.
'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT
Issued by: Date
OURCEREGULATI NS. _
Re -roofs
Signature ofAp licanveontracmr D e
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupam store or handle hazardous material
u defined by the Cupemor Municipal Code. Chapter 9.11, and the Health and Safety
Code Section 15532(.)?
0Yes
All roofs shall be inspected prior to any roofing material being installed.
Will ft applicantorfulumbuilding Occupant use equipment ordevices which
If a roof is installed without first obtaining an inspection, I agree to remove
mit crncd by the Bay Area Air Quality Management
us air comamiHirials
all new materials for inspection.
District,
❑ Yes
I have mad the hrurequirements under Chapter 6.95oftheCal ifnr-
at- Hcalth S Safety Code. Redum 255(15.25533 and 25534.1 understand that if the Wilding
dors not eurmmly haw a enam. Nat it is my respmtsibility m nobly the occupant of the
mgdirrmenttwhich Must xmet �orluisa aeur,Canirrcamofoccupanry.
Signature of Applicant Date
i
All roof coverings to be Class "B" or better
Owner or as rued agent Date